When assessing a client with an ionized calcium level of 17 mg/dL (4.25 mmol/L), which intervention is most important for the nurse to implement?

Reference Range

lonized Calcium [Adult 4.6 to 5.1 mg/dL (1.15 to 1.35 mmol/L)]

Determine apical pulse rate and rhythm.

Observe color and amount of urine.

Assess strength of deep tendon reflexes.

Compare muscle strength bilaterally

Answer and Explanation

The Correct Answer is A

A.   An ionized calcium level significantly above the reference range can lead to cardiac dysrhythmias and requires immediate attention to assess cardiac function.
B.   While urine output and characteristics are important indicators of renal function, cardiac assessment takes priority due to the potential cardiac effects of hypercalcemia.
C.   Assessment of deep tendon reflexes is relevant since hypercalcemia can lead to muscle weakness and diminished reflexes. However, this should be done after assessing for any cardiac dysrhythmias.
D.   Comparing muscle strength bilaterally is important for assessing neurological integrity but is not the priority when hypercalcemia is suspected.

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Correct Answer is D

Explanation

A. While physical activity is important for overall health, it may not directly address constipation. Increasing fluid and fiber intake is a more specific intervention.

B. Stool softeners can be helpful, but dietary modifications should be attempted first before resorting to medications.
C. Gas-producing foods may not be directly related to constipation. The focus should be on promoting regular bowel movements through diet and hydration.
D. Increasing fluid and fiber intake is a recommended first-line approach for managing constipation in older adults.

A. The nurse explaining the need for education to the client. B. The client's belief that his needs will be met through education. C. The nurse's empathy about the client having to self-inject. D. The client seeking family approval by agreeing to a teaching plan.

Correct Answer is B

Explanation

A. While it's important for the nurse to explain the need for education, the client's belief in personal benefits is more motivating.
B. The belief that their needs will be met through education fosters motivation.

C. Empathy from the nurse can enhance the learning experience but might not solely motivate the client.
D. Seeking family approval is an external motivator, but personal belief in the benefits of education is more intrinsic.

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When assessing a client with an ionized calcium level of 17 mg/dL (4.25 mmol/L), which intervention is most important for the nurse to implement? Reference Range lonized Calcium [Adult 4.6 to 5.1 mg/dL (1.15 to 1.35 mmol/L)]

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Explanation

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When assessing a client with an ionized calcium level of 17 mg/dL (4.25 mmol/L), which intervention is most important for the nurse to implement?

Reference Range

lonized Calcium [Adult 4.6 to 5.1 mg/dL (1.15 to 1.35 mmol/L)]